23 Anorectal Cancer

512 Anorectal Cancer

Removal of the Papillon template and needle can performed at the bedside. The sutures holding the template are cut, and the entire system, including the central tube, is extracted en bloc. When a system with needles and anal dilatator in a fixed position are used, it is recommended to remove needle one at a time and finally the anal dilatator. If gently done, this procedure needs neither anaesthesia nor analgesia. Mucositis develops 1 - 2 weeks after the implant. The reaction is maximal after 3 - 4 weeks, and heals progressively in 5 - 8 weeks. Local ointments and, if necessary, oral analgesics should be given

10 Results 10.1 Anal canal

Overall, authors using interstitial brachytherapy as a routine boost technique, report local control rates between 80 and 90% of cases, with severe necrosis rate requiring colostomy not exceeding 5%. At the Centre Léon Bérard, 221 patients have been treated conservatively with the above-described technique for T1 - 3 cancer of the anal canal. Five-year overall survival rate was 66% (12). Local failure rate was 8% and anal function was preserved in 90% of cases. Severe complications were uncommon with, in total, 7 cases needing colostomy. The authors insisted on the fact that these favourable results were obtained because the above described protocol indications were rigorously followed. They in particular recommended that the intersource spacing should remain less than 1.5 cm. At the University Hospital of Geneva, for 125 patients definitively treated with radiation for anal cancer (with a Ir-192 boost in 108), at 5 years, overall survival rate was 66.5%, overall local control rate 83%, and local control rate with sphincter preservation 68% (1). At the Lyon-Sud hospital, 95 patients were treated between 1982 and 1993 for a T1-4N0-3 squamous cell carcinoma of the anal canal with high dose external beam radiation therapy and concomitant chemotherapy with cisplatinum and 5-fluorouracil, followed by a boost with low dose- rate iridium 192 implant (7). At 5 and 8 years, the overall survival rates were 84% and 77%, the cancer specific survival rates 90 and 86%, and the colostomy-free-survival rates 71% and 67%, respectively. A local recurrence was seen in 14 patients. Among 78 patients who preserved their anus, anal sphincter function was excellent or good in 72 (92%). At the Centre Alexis Vautrin, 101 patients were treated from 1976 to 1994 for a T1-4N0-3 squamous cell carcinoma of the anal canal with 36 - 45 Gy external beam radiation therapy and concomitant chemotherapy with 5-fluorouracil and mitomycin C, followed by a 20 Gy boost with a low dose-rate iridium 192 implant (15). Six others had a boost with external beam irradiation, and 12 an abdominoperineal resection. At 5 years, the overall survival rate was 60%, and the specific survival rate 75%; it was 94% for T1, 79% for T2, 53% for T3, and 19% for T4. Thirty-two locoregional recurrences were distributed according to stage into 2, 17, 10, and 3 recurrences for 19 T1, 70 T2, 22 T3, and 7 T4. Severe late complications were observed in 17 patients, and were treated with abdominoperineal resection in 4 and colostomy in 11 (of which 7 were permanent). The rate of sphincter preservation after conservative treatment in cured patients was 100% for T1, 82% for T2, 58% for T3, and 100% for T4.